1864 Junction Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) - Permit _Number
Name - 24 cc Date - -Z/ -�f� i 3678
Locationi2 F=,l C_
40
Subdivision Name Lot No. Sec. or Block No.
Lot Size_d Z, House Mobile Home v Business Speculation
No. Bedrooms 3 No. Baths No. in Family 3 _
Garbage Disposal YES ❑ NO Q' Specifications for System: /6-0-0
Auto Dish Washer YES ❑ NO a
Auto Wash Machine YES [�r NO ❑ ' `3 {- ce-,
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by C Y�1c� � a Q�S '
*Conta-QLa—rep`resentative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
G,�
Certificate of Completion _ Date
*The signing of this certificate shall indicate that the system describVed above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
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APPLICATION FOR )ITE EVALUATION/IMPROVEMENTS PERMIT
�< �bop Davie County Health Department f"
S Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone '
1. Permit Requ pted y c 04111,19 9M., . 1.; Busine s Phone
2. Address & , tw
3. Property Owner if Different than Above
43
Address
4. Permit To: a) InstallZ' Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms— Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes t urinals garbage disposal
lavatory showers—1 washing machine
dishwasher sinks
8. a) Type water supply: Public Private--Counity
b) Has the water supply system been approved? Yeses Z
9. a) Property Dimensions
b) Land area designated to buildin , ite
c) Sewage Disposal Contractor _ .
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Sign t re
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address /2f 7 X/1 Lot Size
iyl
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SS S S
-XM PS
U U U U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay) d�r_> ® cm PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils <�5> 429> ':�M PS
U U U U
4) Soil Depth (inches) � � S PS
U U U U
5) Soil Drainage: Internal � � � S
PS
U U U U
External d � � PS
U U U U
6) Restrictive Horizons
7)'Available Space S S. S S
PS � PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Prov' ' all
Recommendations/Comments:
4,-Lt �P_
Described by -��� Title Date
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SITE DIAGRAM
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DCHD(6-82)